Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Friday, December 15, 2006

Thinking Out Loud....

(I'm hurriedly trying to change the subject from my sorry post below, so I'm rushing to print before fully fleshing out something I'd been working on. In retrospect, I wish I'd not posted my little fiction piece; but I've decided to leave it and move on. Quickly.)

This may sound self-indulgent and egotistical (what? from a surgeon??) but bear with me: I have a point.

I think I can honestly say my patients did well to have me as their surgeon, even as my wife may have gotten the short end, husbandly, and my son likewise, fatherly. By which I mean I spent my career, for whatever reasons, highly devoted to my patients and my practice, at the expense of my family and personal life. I simply had no choice in the matter: it's how I was trained, and what I believed. I was never entirely comfortable ceding surgical care to anyone else, even my closest partners. And for the first few years in practice, until I realized the folly, I even abhorred medical help: I felt obliged to manage even the intensive care of my patients. For a while, I was probably as good at it as the intensivists (of whom there weren't a lot, early on). As time went on, and I (happily) had only the occasional critically ill patient, I came to realize I wasn't the best one for the job. But surgically -- well, I never felt my partners would take as good care as I did. It might also be true that they felt likewise, in reverse. One would hope that all doctors felt that way. Or so I think. Thought. Wonder....

More than just imagining it, I lived it: I made hospital rounds no less than twice a day, and more commonly three. Except on the critically ill or unstable or as-yet undiagnosed: then it was four or more times. Six a.m. Between cases. Before heading to the office. At the end of the day. Go back in in the evening. I always took calls on my patients, whether I was the "on call" doc, or not. If a patient needed a re-operation, I'd usually do it -- on call or off. Although I think I may have overdone it, I'd say most surgeons of my era have similar commitment, if for no other reason than hearing the admonitions (to put it mildly) of our mentors in our heads. But it's more than that. To choose surgical training twenty or thirty (fifteen, ten) years ago was eye-openedly to enter into a contract; to agree that caring for patients was going to be the prime directive, and that it would be a never-ending commitment. That it was pounded in over and over for six or seven years of nearly twenty-four/seven training simply reinforced what was already implicit.

Considering my behavior mostly in hindsight, I have questions. How necessary was it? Did it really make a difference? Was it essential? Or delusional? An excuse for other shortcomings? In semi-retirement, it's clear my sense of irreplaceability was an illusion. But what of the rest? My younger partners never rounded as much as I. Unlike me, they took their full days off, and their allotted vacation days; weekends off were off. Their patients did well enough. Complications, for the most part, have their roots in the operating room. Data, when they were made public, confirmed my complications were fewer; but I think it had little to do with my post-op care. I do think those habits were part of why my over-all costs were less: in rounding frequently, I was able to expedite necessary testing and to get orders written sooner, discharge more efficiently. (Bureaucracy alert: the powers that be once decided to review afternoon discharges, intending to encourage doctors to make rounds in the morning to get patients out earlier. Afternoon discharges were to be some sort of black mark. Making rounds multiple times, I often discharged patients in the afternoon because some mornings they weren't ready but were later. I pointed this out to the medical director, asking if he'd rather I not make those afternoon rounds and wait till the next day, in order to avoid being dinged. The plan ended.) If my patients didn't have to get to know another surgeon during their hospital stay, if their hospital bills were lower, to whom did it really matter? No one mentioned it to me, much.

So what's my point? This: if any of this stuff actually did matter, I think it's moot. It's my sense that, as a generalization, things are changing fast. I'm not the first to blog about the recently restricted hours of trainees. In fact, nothing I'm saying is particularly original. I do, however, have several friends who are surgical professors in some high-level training programs, and I'd say it's unanimous among them that they are concerned about the surgeons of the future. "Shift-worker mentality" is a common theme in our conversations. The current crop of trainees, they say, aren't as committed as we were. They're happy to diddle around until the next shift arrives to solve a lingering problem. More importantly (but maybe a bit off the subject of this post), there's concern that the restricted hours lead to less experience, which works its way up the hierarchy: fewer hours means fewer operations. Senior residents are less likely to let the juniors do cases, which means those juniors, when senior, are less experienced. The need for formal mentoring after training is a concept being discussed seriously.

It's not entirely clear-cut: are patients better served by doctors less single-minded? The restrictions on hours resulted from a lawsuit over a death presumably due to mistakes by a fatigued resident. Avoiding fatigue, clearly, is desirable. But limiting experience? Selecting people less willing to make a full commitment? I imagine patients prefer a well-rested doctor. But one that plays the piano? Skis like a maniac? Coaches Little League? Not sure. Really. Not sure.

I burned out. After twenty-five years, chronically tired, dreading the phone-calls, missing family gatherings, I managed to wangle a temporary (I thought) leave of absence. It felt so good, I couldn't convince myself to go back to full practice. Had I been less crazily compulsive, maybe I'd have lasted longer; maybe I'd have, over a longer career, cared for more people (part of my problem was never saying "no." I did twice as much surgery as my partners, more or less.) So maybe it's better, from a cost-benefit sort of calculation, to have docs who want and have a life. And this: whatever else is true, the new crop aren't idiots. Surely they hear the cries; they know about decreasing reimbursement, malpractice, interference from all points of the compass. If there's much about the job that's become abhorrent, why give up your life for it? That's my point: is the current trend a bad thing, or a good one? Honestly, I don't know. Until a few years have passed, no one else will, either. And if it's true that the people choosing medicine now are different from those of a couple of decades ago, or have different expectations, I don't blame them. The essential rewards of being a physician, the privilege of caring for people, remain at the core: but the pleasures have become elusive, diluted by the myriad of impediments disguised as controls. It's illogical to expect docs to walk in the same way on ground that has fundamentally shifted under them.

25 comments:

Anonymous
said...

o boy, Dr. schwartz! that was a good blog! I'm planning on doing surgery when I grow up (I'm a med student), but I sure do not want to give up my life entirely for it. My dad is a surgeon and I felt the brunt of it while growing up. Never go out of town, family gathering with missing dad. He is a great dad overall, but still... missed him sometimes.

That was quite a good post Dr. Schwab.I'm still an undergrad at my university, but I too want to become a surgeon, and if it makes you, or anyone else feel better, I intend to squeze in more hours than I'm "allowed" too. (no really I didn't already do 24, I only did 12, I'm up for another shift)

but in all seriousness. It does worry me that maybe when I get to residency I won't be getting training that's as good as that of my predecesors.

the real question is what, besides trying to work the system for as much training as I can get from it, can I do about the lessened hours, and about the difference in training.

I do realize that the state of medicine has shifted drastically, and if going into medicine were any sort of rational desicion (as in where am I going to make the most money/ where am I going to have the most free time) then it would make sense to adjust my attitude towards how much freetime I should expect, and to how much I need to dedicate myself. There is one problem with that though.The choice to go into medicne (esspecially surgery) is not a rational one. We're expected to spend the rest of our lives doing things by logic and testable methods, but that choice that makes us go into medicine, is at the root of it a completely illogical, unscientific, emotional choice. the way I figure it is that there have always been good and bad and in between doctors and surgeons.maybe these changes will make it harder to have so many good ones, but just as you've said, the difference between a great surgeon and a good one generaly makes little difference in regards to the patient. the great surgeons patient will recover more quickly, but in the end, a successful apendectomy is a successful apendectomy.

what this all boils down too, is that the people who are called to surgery, and called to medicine, will still go into it, and will still (sometimes to the point of neglect and stupidity) dedicate themselves completely to their patients. It's not the sort of thing I would really have expected of myself, but I know that when I'm done with all of this, I'm going to be a doctor first, and whatever else I am second, whatever that means.

and hopefully the ammount of the people going into medicine who are indeed called to it, is the same as it once was.

the way I figure it, only if fewer people feel called into medicine do we have a problem on the doctor side of it.

it's not arguable that we have a problem on the system portion of it, all around.

"The best preparation for tomorrow is to do today's work superbly well."

I firmly believe that there is a difference in the quality of care provided by a physician who is driven to excellence vs. another who is satisfied with good enough.

I suspect that you realize that you would (could?) never have done things any other way. Perfectionism is both a blessing and a curse. To give patients less than your very best would be intolerable. You are rightfully proud of your accomplishments.

As I remember it, and I remember it well,internists who trained 30 and 30 plus years ago ago also had a certain attitude transmitted to their limbic brains.An atttitude and an approach of a life long committment to learning about medicine and caring for your patients. Patient care was primary, the duty was to the patient.This transformation from lay person to dedicated physician happened not just in the medicine residency but in med school as well.Many of my parters and(I hope I) played that out over the years.From what I see of the current IM training programs and the concerns expressed by the teachers it seems very unlikely that the approach to medical practice tomorrow and later will be what it was.There is a lot more that can be said about that,maybe later I will.For now, let me say-my hat is off to you for doing over the years what physicians are supposed to do and for being the kind of surgeon I would have called to see my patients or to operate and care for me.

As a resident I hear this mantra quite a bit. My former chairman has written several editorials on training "Generation X" (although I'm technically Gen Y). The fact is that most of my generation (including me) won't accept surgery as life. It's a great job. I love it and I'm willing to work very, very hard at it. But when I'm not on call, I turn off my pager. I need other things in my life besides my patients and the OR.

south africa is only now moving into the new era of training. and it has not yet permeated all our universities. our training was in the old school where your patient is your patient and your complication is your problem, post call or whenever.

the other fact that we are seeing is in our country no one wants to study surgery any more. who wants to put themselves through that? for what reward? i agree with dr schwab in that we don't yet know what the answers are. the drive in our country to make surgery training easier or at least not as tough has to do with the fact that we just are not getting enough people to join the programs. but i do think it will translate to a different level of care. the future will tell i suppose.

I decided to do a surgical residency before I found out how kind and gentle and compassionate surgery is becoming. Right now I'm sifting my possibilities, looking for the most old-fashioned, dedicated program I can find. I don't want to be at the program (which I recently interviewed at) which boasts that their residents usually only work a 60-hr week, that working longer is ridiculous because you make worse decisions when tired (so we shouldn't practice for that, then?). It was at this program that I heard the line, which I am still gagging from, "It's really only necessary to review the labs and vital signs on patients in the ICU; you don't gain anything from actually seeing the patient." And, "There's no point to rounding on patients early in the morning. It benefits no one." This, from "forward-looking" people on the board of ACS. So, I intend to go to the most uncompliant, backwards, unprogressive training program I can find. :S

Dr. S.,I'm not a surgeon, or even in the medical field, except as a patient. I think I can safely say that most of us would want a surgeon (or doc) such as yourself, who goes the extra mile. And your example as a dedicated professional is part of your parenting. I am very pleased to see the introduction of things like Medical Humanities at med schools and the schools' attempts at teaching docs-to-be to be more human. At our local med school there are various extra-curicular activities such as drama clubs and chorales for the med students, not to mention regular art shows by the students. It is a different outlet from the "science" that surounds the students 24/7.Knowing that our local docs are also sculptors, painters, singers, church youth leaders(such as my family doc), and writers (such as yourself) makes me appreciate them more as "people". Perhaps a more "humane" approach to training docs will encourage more to enroll in med school (and thus increase the numbers of docs)and eventually reduce the crazy hours that "old school" docs worked. The work hard ethic, while admirable from a professional point of view, wreaks havoc on the home life. And this is evident in most professions, not just surgery. As an adult, I appreciate my parents' choices. I may not have when I was 12. Thanks again for another thought provoking post and the chance to add my two cents worth.Shauna

You've hit the nail on the head, both in the fact that times have changed and the grumpy old professor shift mentality griping.

I get so tired of hearing about it. Yes, if our patients regarded us as god, if we got paid $700k (adjusted for inflation), if we got sleep on call, if malpractice wasn't out of control, we would probably be willing to put up with what you did. But that's not the case. If the BS in medicine spikes, then the best option is to spend less time in medicine.

the state of affairs is still somewhat different where i come from, but you can definitely see a difference across the generations. how the senior consultants give so much more patient care than the registrars.

i love surgery, i'm hoping i can go into the surgical field someday if i do manage to get in! and i hope my teachers will be as inspiring as you. =D

That was a lot to think about, and I'm not sure where I fall on it yet...

I think there is a fine line between dedicated and committed to patient care, and needing committed due to over zealousness..

but where is that line... I heard several of our ED docs arguaing about the residency hours rules, and whether todays doctors lose out on the total immersion that their generation got... but was the price of that total immersion the safety of a patient?

These are all great comments, on a subject about which I am myself ambivalent; particularly in wondering whether I burned myself out unnecessarily. I think surgical training can't avoid being hard, and shouldn't. I also don't begrudge those who seek ways to find balance in their lives. And mainly, whatever else is true, the fact is that for the most part, to the extent outlooks of physicians are changing for the worse, it's not their fault: it's the inevitable result of the current US approach to healthcare costs: pay less, get less.

I feel compelled specifically to respond to Alice: Wow. Just wow. I'm speechless over your description of that program and hope it disappears from the face of the earth. It's as far from my sense of reality as it can be. I can't tell you (and evidently don't need to) how many important things are discovered on morning rounds, and how many efficiencies result.

Dr. Schwab - I deeply regret to state that, much as I wish that program and its directors would disappear, they gave the definite impression that they intend to and expect to be setting policy for the ACS and the RRC within the next ten years. They named names of programs which come to them to learn how to "teach" surgery. If you have any connection to ACS at all, I wish you would try and throw some wrenches in their plans. Perhaps circulate some of your famous memos to the subscription list of the surgery journals.

As a first-year medical student in Canada, your blog post made me pause and read it twice.

I've been interested in surgery for some time, and have of late found myself questioning my interest. I realize there's lots of time until I have to decide on a residency, but the whole idea of the responsibility that comes with being a surgeon appeals to me. Maybe it's the perfectionist in me.

But I don't want to work 70+ hours a week. I could tolerate it for residency, but I do want to have a family. Having been on the receiving end of a father who worked 70 hours a week, I want to see my children. I find myself looking at specialities that would allow me to be home for dinner. And then I feel guilty for not wanting to put my patients first.

There's certainly no easy answers. Even my girlfriend has admitted that she's had to reconcile herself to the fact that if we get married, she would be marrying me as someone who's also married to his job. Her generosity astounds me and I am immensely grateful, but it also makes me wonder if this is the way things should be.

I've seen the beginnings of the limited-hour work week for our residents, and honestly, I can't tell much of a difference.

There's an emphasis on perfection in the neurosurgery program, as you'd want there to be, so the residents usually work more hours than they're allowed. If it's not at our facility, they're moonlighting at one of the other three hospitals in our system. If they *don't* moonlight, they're seen as not as dedicated as those who do, and don't do as well or advance as fast.

So I still see the residents on, say, the vascular service after they've gotten four hours' sleep in 96. While that might be the old norm for surgical training, it makes me...well, it makes me nervous.

The other specialties have cracked down on hours much harder than NS has. I'm seeing more ortho and IM residents now who are better rested and making better decisons, but more neurology residents who are stuck rotating among three hospitals because they're the only ones on call for a given night.

What bothers me more than the possibility of a "shift worker" mentality among new doctors is the short-term effect of the policy change on our residents. I think the "shift worker" panic is overblown--people who want to work in medicine and nursing are, by nature, not prone to leave until the job is done.

But the hours change, in the short term, is frustrating some residents who want to work more but can't, and burning out others who can't get backup for a four-day call.

Reducing hours was the most obvious change Thems In Charge could make in the name of safety...but I predict that we'll see a number of tweaks and small changes in the next five years to that policy.

i just feel patients need dedication and surgical patients need extra dedication. they often have this nasty habit of trying to die. as shauna said, from the patient's side, dedication is the quality they'd desire in their surgeon. yes somehow we need to reconcile our own personal lives etc, but that type of training alice refers to will produce surgeons of lower quality and better personal lifestyle. once again from the patients point of view???

also the idea of not being able to function when tired?? well in the real world patients don't attempt their party trick of trying to leave this mortal coil only after first checking with their surgeon to see if he's well rested. the reason the training is rigid is because the job requires that level of dedication.

the problem as i see it is that there are very few people willing to go through what it takes to become a surgeon and therefore very few people who are willing to be a surgeon.

if i could make the quick comparison with a special forces soldier. the training is rigorous because the final product has to be good. lives may actually depend on him.

because of the immense shortage of surgeons in our country this is all topical here now and therefore i have given it much thought, but maybe i should save that for a future blog of my own.

Bongi: "also the idea of not being able to function when tired?? well in the real world patients don't attempt their party trick of trying to leave this mortal coil only after first checking with their surgeon to see if he's well rested."

Despite what they often like to believe, surgeons are not irreplaceable. I always laugh when the old die hards cloak their desire for us to make the same sacrifices they did (i.e. hazing) in the idea of patient safety. Yes, clearly the solution to "people suck at doing stuff after being awake for 30 hours" is "make people stay awake for 30 hours a lot and they'll learn to be less tired!", not "have surgeons who have not been up for 30 hours".

The other thing that makes it obvious that "training" is just a thin ruse for "I went through it so should you" is the fact that they never do anything to actually improve resident learning. I know (and I doubt anyone who has worked in a hospital will disagree) that a young surgeon could learn more in 88 hours if you had someone helping cut down on his paperwork and wasted clerical time than the old 120 hour resident would spending 8 hours a day doing paperwork. But that will never happen, because it's not about education, it's about hazing and cheap labor.

I liken dedicated surgeons, such as yourself and my trauma surgeon (I had a ventriculostomy and was in a coma 16 years ago), to a soldier who makes the ultimate sacrifice for his country. I remember a few people who told me after I woke up how much time my doctor had spent with me. Time like this is invaluable, beyond measure, and lasting. When I came out of my coma I didn’t have much of myself or what I knew left (I had frontal lobe and brain stem bleeding; swelling, and bruising), but because of the time that my trauma surgeon spent with me I must have unconsciously cleaved to different aspects of him that I admired, such as the aspiration to prevail. When I woke up the first element to my then altered personality was gratitude, and gratitude is still the cornerstone of who I am. If he hadn’t given me so much of his time - if I hadn’t taken so much of his time - I can honestly tell you that my recovery would not have been so full. As much as his gift of healing, he gave me the gift of hearing his voice and closeness with him. As a surgeon, no matter how “self indulgent and egotistical” you are, its impossible for you not to be the most humble people in the world through the very amazement of the sacrifice that the best of you give.

Dr Schwab, I believe you when you say that your patients did better than those of other surgeons. I even agree partially that it was because you picked up on problems and dealt with them when they were small and easy to deal with rather than full blown disasters.

More important, in my estimation, is that the nurses never knew for sure when you were going to show up, and they always gave your patients first priority, so that they would be able to assure you that your patients were getting good care, that their meds were given on time, dressings changed properly, and other needs attended to. They knew that you would be there to make sure that these things were done, and done right. Whether out of fear, respect, or awe, that's what they did. I'll bet you agree with this.

jb: interesting point. I hadn't thought about it exactly in that way; although I know they knew I was sort of fanatical about little things, and frequently picked up problems. I'm not sure they entirely appreciated my occasional rants; on the other hand, lots of them came to me or sent their family when they needed a surgeon.

ah, the recurring question...Weighing in as an orthopedist who began training before the 80 hr work week and finished training with the 80 hr work week, I can tell you that there's a lot of hand wringing about the lack of commitment of the "newer, lazier generation"At the same time, medicine can't attract the brightest and best if they can't reward them with money, prestige, good feelings or good quality of life.When I was a med student in NYC, many fellow students had gone to college with people who were now in the financial services arena who were making money (lots of it) rather than going into debt (lots of it). There was some resentment.If you can't make medical decisions without being second guessed by administrative bean counters and misinformed patients who have recently surfed garbage on the internet or being vomitted on and cursed by intoxicated trauma patients, you might choose a profession where the administrative "minions" and the clients are all either respectful or at least bathed and domiciled.But if you're going to go into surgery or any other high stakes medicine, the sorry truth is that you will know your patient better and make better decisions for them if you have been in the hospital from 5 to 9 than if you are in the hospital from 9 to 5. No need to exceed 24-30 hrs on call - you really do get a little fuzzy esp doing routine tasks after being up >24 hrs but I never knew the patients better than when I was on neurosurgery and was there 16 hrs a day. You realized there was no life except eating when you could, sleeping when you could and working, but virtually nothing happened without you knowing about it. You could be relatively well rested but you could not have any outside life. Good or bad? Well, for ortho, it's only 5 years and really only as an intern and as a junior resident so 3 years. It's doable, it sucks but if you're committed, it's worth it and you _do_ learn the most on call and when you put the extra hours in and see that post op patient, that patient with shortness of breath, that patient's family after the bad outcome.I worked a freakin 60-70 hour work week as an engineer before I went to medical school without the hour boost of being on call/working weekends so people whining about residents being overworked and too tired to make good decisions need to understand the huge difference between working 100 hrs a week (evil and burnout inducing) and 80 hrs a week (all in a weeks work for a committed professional) And now that I'm out of residency, the hours are better and the pay is too.My last comment will be a little off topic, but I've always felt it unjust that general surgeons make so much less than radiologists, gastroenterologists, anesthesiologists and dermatologists when they work much worse hours, have so much more responsibility and poorer "quality of life." Now that being an investment banker carries more cachet than being a surgeon plus a fatter paycheck, who's going to want to round before, between and after cases, be called in the middle of the night to drain pus on someone who is uninsured when you could be at Ruth's Chris closing a deal or out sailing after finishing reading those chest xrays at 4 PM?

I would've loved having you for a surgeon and felt as safe and well cared for as a patient could be under frightening circumstances. Sounds like you would've been the anchor in the storm as well as the healer.

Too bad you couldn't take more time for yourself in whatever way you would've liked.

I understand wanting to follow through on your own work.

Throckmorton... another blogging surgeon said this in one of his posts this summer "If you ask a surgeon to name the two best surgeons he knows of, he will have a hard time naming the other one."

About Me

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.